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1. That he/she has read all the provisions of this application,and that the description included in this application are correct to the best of <br /> his er biowledge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner;and <br /> 3. That he/she wig assume full responsibility for all liability for persona;injury or damage to property which may arise out of the work <br /> described above,or which may arise out of his/her failure to do the work provided herein;and <br /> 4. That in the est any carr of such l"rabillity is made against the County of San Joaquin or any department,official or employee <br /> thereof,he shall dekA indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> indicated site with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is granted as requested,he gees to do the work described in accordance with all terms,condition and restriction <br /> of this and any attached sheet,in ded as general or special III provisions. <br /> Z?9&0010 <br /> Soature of Appficant Title a e <br /> »»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1 DRIVEWAY: None ❑ Dirt [ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None❑ Existing—Type <br /> ',alt <br /> Other*es in neighbafhood Yes No Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No &K <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS along Wt-of-Way "$' <br /> 7. DITCH: Yes [ Na ❑ If Yes: V Styie [y ' 12 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Pam with "Min Depth A.C.over "Min Depth'/4"A.B.over <br /> Notes: > :,. <br /> 2. PIPES: Length of Pipe Required t.V Ft.and Diameter of Pipe inches) <br /> To be connected to any adjacent driveway pipe Yes ❑ No ❑ <br /> Drainage Inlet Required Yes ❑ No ❑' <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> I <br /> 3. HEADWALL: Yes ❑ No 211'~ <br /> 4. PAVED FRONTAGE: Paved with ' ` "Min Depth A.C.over "Min Depth'/<"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»y»»»»»»»»»»»»»»>FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 <br /> M <br /> 110.00 ❑ Paved Frontage $116.00+0.53/ft. <br /> /orw/oprpe $ Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> /box Culvert $179.00 <br /> IISJPWGOV.ORGI%MESICENTR&SUMMSaERI oja-SWWKWASTER.PSIENCROACHMENT PERMIT DRIVEWAY.DOC (10109) Page 2 of 2 <br />